STATE OF WASHINGTON
DEPARTMENT OF SOCIAL AND HEALTH SERVICES
CHILD CARE SUBSIDY PROGRAMS (CCSP)
CCSP Application
Date: / PARENT/GUARDIAN
CASE NUMBER
_____
FOLD
Dear Applicant:
We will process your application for child care subsidy and determine eligibility once you provide the following information:
- CCSP application(you must completea child care application even if you are in a WorkFirst activity).
- Proof of the last three months of household income (such as pay stubs, child support, Social Security Income, Supplemental Security Income (SSI), and any other income received by someone in your family). Include your employment schedule. You don’t need to provide proof of income for cash assistance from the state (TANF).
- If you are newly employed and have no pay stubs, we will accept a statement from your employer with a hire date, how much you are making (per hour, salary, etc.), and what your schedule will be. If your employer is unable to verify this information, we can take your verbal or written statement. When you provide a verbal or written statement to verify employment, you must provide a copy of your wage stubs within 60 days of approval.
- Proof of any court or administrative ordered child support payments made in the last three months.
Children have the basic human right to be safe. Abuse and neglect threaten children’s safety by placing them at risk of physical and emotional injuries and even death. If you suspect a child is the victim of abuse or neglect, call DSHS toll free at 1-866-END-HARM (1-866-363-4276).
CHILD CARE SUBSIDY PROGRAMS (CCSP)
CCSP Application
Incomplete information may delay approval for
services and payment. Type or print clearly. / Seasonal Child Care
Applicants must:
- Live in Adams, Benton, Chelan, Douglas, Franklin, Grant, Kittitas, Okanogan, Skagit, Walla Walla, Whatcom or Yakima Counties;
- Work in a farm-based employment which includes cultivation, production, harvesting or processing of fruit trees or crops.
DATE
APPLICANT’S NAME / CLIENT ID NUMBER / BIRTHDATE
APPLICANT’S ADDRESS / SSN (OPTIONAL) / TELEPHONE NUMBER
CITYSTATEZIP CODE / APPLICANT’S ETHNICITY RACE / APPLICANT’S GENDER
Male Female
Is your family experiencing homelessness? Yes No (Examples include: living in a motel, shelter, transitional housing, car, public space, or doubled-up with others due to loss of housing or economic hardship.
CHILDREN FOR WHOM YOU ARE RESPONSIBLE LIVING IN THE HOUSEHOLD
NAME (LAST, FIRST, MIDDLE INITIAL) / BIRTHDATE / MALE/ FEMALE / ETHNICITY (OPTIONAL) / SSN (OPTIONAL) / U.S. CITIZEN OR LEGAL RESIDENT / RELATIONSHIP TO APPLICANT
Yes No
Yes No
Yes No
Yes No
DETERMINING WHETHER YOU ARE A SINGLE OR TWO-PARENT HOUSEHOLD - REQUIRED
Do you live with a spouse or another parent / guardian of any of your children? Yes No
If no, complete the Single Parent Declaration form, DSHS 27-164, and return with your application.
If yes, complete the information below.
SPOUSE OR OTHER PARENT’S NAME / BIRTHDATE / SSN (OPTIONAL) / RELATIONSHIP TO APPLICANT / RELATIONSHIP TO
ABOVE CHILDREN
APPLICANT / SPOUSE OR SECOND PARENT/GUARDIAN
NAME OF EMPLOYER, WORKFIRST ACTIVITY, OR SCHOOL
ADDRESS (EMPLOYMENT, WORKFIRST ACTIVITY,OR SCHOOL)
TELEPHONE NUMBERDATE STARTED
IF YOU ARE EMPLOYED, HOW OFTEN ARE YOU PAID AND YOUR GROSS WAGE PER PAY PERIOD (BEFORE TAXES, INCLUDE TIPS)?
Weekly Every two weeks
Twice a month Monthly$ / NAME OF EMPLOYER, WORKFIRST ACTIVITY, OR SCHOOL
ADDRESS (EMPLOYMENT, WORKFIRST ACTIVITY,OR SCHOOL)
TELEPHONE NUMBERDATE STARTED
IF YOU ARE EMPLOYED, HOW OFTEN ARE YOU PAID AND YOUR GROSS WAGE PER PAY PERIOD (BEFORE TAXES, INCLUDE TIPS)?
Weekly Every two weeks
Twice a month Monthly$
MONTHLY SOURCES OF EARNED/UNEARNED INCOME FOR ALL FAMILY MEMBERS
Include copies (for the last three months): / NAME
SELF / NAME / NAME / NAME
Employment (gross, before taxes, include tips)
Self-employment
Temporary Assistance to Needy Families (TANF)
Child support received
Social Security (SSI, SSA)
VA, Disability, L&I, or Unemployment benefits
Aged, Blind or Disabled (ABD benefits)
Do you pay court ordered child support? Yes No Monthly amount: $
Do you have a court order to receive child support? Yes No Monthly amount: $
DSHS 14-417 (REV. 07/2018) / /
AVAILABLE RESOURCES
Do you have available resources valued at $1,000,000.00 or more? Yes No
Examples of available resources are: cash, bank accounts, stocks / bonds, investment accounts, investment real estate.
PARENT/GUARDIAN’S ACTIVITY SCHEDULE
APPLICANT / SPOUSE OR SECOND PARENT/GUARDIAN
ACTIVITY (EMPLOYMENT, SCHOOL, WORFIRST ACTIVITY) INDICATE TIME WITH A.M./ P.M. / ACTIVITY (EMPLOYMENT, SCHOOL, WORFIRST ACTIVITY) INDICATE TIME WITH A.M./ P.M.
Monday / WHAT IS YOUR SCHEDULE FOR EMPLOYMENT,
SCHOOL, WORKFIRST ACTIVITY? / WHAT IS YOUR SCHEDULE FOR EMPLOYMENT,
SCHOOL, WORKFIRST ACTIVITY?
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What date will child care begin:
Applicant: If known, how long does it take you to travel from your provider to your activity (work, school, etc.)?
Other parent/guardian: If known, how long does it take you to travel from your provider to your activity (work, school, etc.)?
CHILDREN’S ACTIVITY SCHEDULE. FOR ADDITIONAL CHIDREN, ATTACH A SEPARATE PIECE OF PAPER WITH THEIR INFORMATION.
CHILDREN’S NAMES / SCHOOL SCHEDULE
(EXACT DAYS AND TIMES) / CHILD CARE SCHEDULE
(EXACT DAYS AND TIMES)
Will your school age children need care during school and summer breaks? Yes No
Do you have a child with Special Needs? Yes No / If yes, please contact the Authorizing Worker for information about special needs payment rates.
Voter Registration
The Department offers voter registration services as required by the National Voter Registration Act of 1993. Applying to register or declining to register to vote will not affect the services or amount of benefits that you may be provided by this agency. If you would like help in filling out the voter registration form, we will help you. The decision whether to seek or accept help is yours. You may fill out the voter registration form in private. If you believe that someone has interfered with your right to register to vote, to decline to register to vote, your right to privacy in deciding whether or not to register, or your right to choose your own political party or other political preference, you may file a complaint with: Washington State Elections Office, PO Box 40229, Olympia WA 98504-0229 (1-800-448-4881).
Do you want to register to vote or update your voter registration? Yes No
Hearing Rights WAC 110-15-0280
If you disagree with this decision, you may request a hearing by contacting this office or write to Office of Administrative Hearings, P O Box 42489, Olympia, WA 98507-2489. You must request your hearing:
- On or before the effective date of this action or no more than 10 days after we send you notice of this action, IF you receive benefits now and you want them to continue, or
- Within 90 days of the date you receive this letter.
I declare under penalty of perjury that the information given by me in this declaration is true, correct and complete to the best of my knowledge and realize that willful falsification of this information by me may subject me to penalties as provided in Washington State Law. (RCW 74.08.055)
FIRST PARENT/LEGAL GUARDIAN’S SIGNATURE / DATE / SECOND PARENT/LEGAL GUARDIAN’S SIGNATURE / DATE
Discrimination is prohibited in all programs and activities: No one shall be excluded on the basis of race, color, religion, creed, national origin, gender, age, marital status, disabled veteran or Vietnam-era veteran status, or handicap.
CCSP APPLICATION
DSHS 14-417 (REV. 07/2018)